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Abstract

Individuals with severely disabling mental illness receive more benefit from supported employment initiatives than from other vocational services, but these initiatives show variable job tenure and low implementation by governments. For those with less severely disabling mental illnesses, such as depression, evidence-based treatment results in substantial restoration of job function, and restored work function occurs in synchrony with reduced symptomatology. However, there is a substantial degree of residual impairment despite receiving standard treatment. Major research trends include an increasing focus on occupational recovery in less severe forms of mental illness and potential application of integrated disability management models to occupational recovery from disabling mental disorders. Promising research directions include effectiveness of standard mental healthcare in restoring work function; effectiveness of actively managing co-morbid mental health problems for disabling physical disorders; population factors affecting return to work in those with disabling mental disorders; identification of policies fostering occupational recovery for disabling mental disorders; effectiveness of innovative mental healthcare focused on occupational recovery; and organizational interventions to foster occupational recovery in employees with disabling mental disorders.

Introduction

The purpose of this paper is to discuss research issues related
to disability management, return to work and treatment as they
relate to people with mental health problems and mental illness in
the workplace. The current report is one of a series of discussion
papers being developed by a Working Group mandated by the Institute
of Population and Public Health (IPPH) and the Institute of
Neurosciences, Mental Health and Addiction (INHMA) of the Canadian
Institutes of Health Research (CIHR) for the purpose of advancing
research and increasing available evidence in the area of workplace
mental health.

The paper has three main objectives:

to report on the state of knowledge in the area

to identify major trends in research

to identify significant gaps in knowledge with suggestions for
promising research directions

In order to achieve these objectives, a review of the scientific
and "grey" literature was undertaken and a small group of
researchers who have studied occupational disability in people with
mental illness were interviewed.

Current State of Knowledge

Knowledge Related to Physical Health Problems

There has been significant research activity on workplace health
that has considered disability management, return to work and
treatment. For the most part, however, such research has not
directly addressed mental health problems or mental illness but
have been focused upon various physical health problems encountered
in the workplace (e.g., back injury and other musculoskeletal
problems, brain injury, cardiac illness and chronic rheumatic
diseases). Although the findings do not tend to address mental
health problems directly, they may provide valuable information
about mental health and may be useful for future research concerned
directly with mental health and mental illness. Some of the
relevant research findings are highlighted in this section.

Consistent across a number of health problems in the workplace
has been the finding that the likelihood of an individual returning
to former employment after an absence from work is determined by a
number of factors other than the nature and severity of the health
problem (Brewin et al. 1983; Kenny 1994; Shaw et al. 2001).

Predictors of a more rapid recovery and return to work include
socio-demographic characteristics, job satisfaction and referral to
appropriate rehabilitation services (Brewin et al. 1983; Kenny
1994). In a study of disability and return to work following
occupational low back pain, a systematic review examined 361
studies and selected 22 that met specific inclusion criteria (Shaw
et al. 2001). The factors associated with protracted disability
included low workplace support, personal stress, shorter job
tenure, prior episodes, heavier occupations with no modified duty,
delayed reporting, greater severity of pain, more significant
functional impact and extreme symptom reports. On the basis of the
evidence gathered in the study, the following measures were
recommended to help physicians improve disability management: the
use of standardized questionnaires, improved communication with
patients and employers, provision of recommendations for specific
return to work accommodations, early intervention and use of
behavioural approaches to pain and disability.

A review of scientific literature related to workplace
disability management for musculoskeletal disorders (Williams and
Westmorland 2002) found employer participation, a supportive work
climate and cooperation between labour and management to be crucial
factors facilitating return to work.

A systematic review undertaken to determine the effect on time
lost from work of physical conditioning programs for workers with
back and neck pain (Schonstein et al. 2003) found that physical
conditioning programs that included a cognitive-behavioural
component could produce a clinically worthwhile reduction in the
number of sick days taken at 12 months (average of 45 days; 95%
confidence interval [3, 88]), compared to general practitioner care
or advice for workers with chronic back pain. There was little
evidence of an effect on time lost from work of specific exercise
programs that did not include a cognitive-behavioural
component.

A three-year follow up study evaluated a randomized intervention
for low back pain in which the intervention group received early
intervention through a clinic, which provided information,
reassurance and encouragement to engage in physical activity (Molde
Hagen et al. 2003). The intervention group had significantly fewer
days of sickness compensation (average 125.7 days per person) than
the control group (169.6 days per person), whose members received
usual care through their own physicians. This difference was
primarily due to more rapid return to work during the first year.
Economic returns of the intervention were calculated in terms of
increases in the net present value of production for the society
because of the reduction in number of days on sick leave. Net
benefits accumulated over three years of treating the 237 patients
in the intervention group amounted to approximately $2,822 per
person.

A number of studies have investigated potential difficulties in
physician approaches to disability management and have report mixed
results (Anema et al. 2002; Dasinger et al. 2001; Guzman et al.
2002; Mahmud et al. 2000). Most have found that physicians' actions
related to disability management are inconsistent with recommended
clinical practice guidelines and policies, such as those set out by
the Canadian Medical Association (Kazimirski 1997). Mahmud and
colleagues (2000) found disability to be significantly associated
with increased utilization of specialty referrals, use of
specialized diagnostic tests and prescription of opioids. They
found that patients with low back pain whose treatment course did
not involve extended opioid use and early diagnostic testing were
3.78 times more likely (95% confidence interval [1.6, 8.9]) to have
gone off disability status by the end of their study. Dasinger and
co-investigators (2001) found positive recommendations by
physicians to be associated with a 60% greater rate of return to
work in "sub acute and chronic disability" (i.e. >30 days of
disability) following back injury. However the association between
positive recommendations by physicians and return to work for
patients "acutely disabled" (i.e. <30 days) was found to
disappear when injury and workload characteristics were taken into
account.

Knowledge Related to Mental Health and Mental Illness

Research on vocational rehabilitation related to mental health has
primarily involved people with severely disabling mental illness.
In trying to understand better the work integration processes of
people with severe mental problems, detailed descriptions of the
different vocational services/programs have been undertaken
(Cochrane et al. 1991). Trochim et al. (1994) tried to describe
them along a continuum of services, with sheltered work as a first
step, transitional work as a second step and supported employment
as a subsequent step. Of all these vocational services, supported
employment, which appears to have been studied the most, has
yielded significantly higher work integration results than other
vocational services (Crowther et al. 2001).

Although supported employment has been found to be more
successful than other programs directed toward people with severe
mental illness, it still encounters difficulties, such as
variability in achieving successful job tenure. It has also seen
relatively minimal adoption by governments and administrations
(Bond et al. 2001). In recent years, many studies of the work
integration of people with severe mental disorders have been
published; they have investigated vocational outcomes in relation
to clinical and economic correlates (McGurk and Meltzer 2000;
Latimer 2001; Rogers et al. 1997), to psychosocial individual
variables (Midgley 1990) or to specific work-related variables
(Macias et al. 2001; Mueser et al. 2001). There have also been
promising interventions using psychosocial approaches to improve
occupational function in people experiencing severe mental illness
as a result of schizophrenia (Liberman et al. 1998; Reker and
Eikelmann 1997) and bipolar affective disorder (Craighead and
Miklowitz 2000).

Fewer research studies have examined disability management or
return to work in relation to people with less severe mental health
problems or disorders. Those that have done so, however, have found
that, despite policies to the contrary in the United States, few
accommodations are made by employers for mental health disability
(MacDonald-Wilson et al. 2002; Zwerling et al. 2003). A
retrospective cohort study of the quality of rehabilitation
provided to workers with adjustment disorders in the Netherlands
found that four of the ten performance indicators measured were
adequate in less than 50% of the time, when measured against
clinical guidelines (Nieuwenhuijsen et al. 2003). Overall, optimal
care was found to have been received by only 10% of the cohort.

Evidence-based treatments for major depression have been shown
to yield corresponding improvement in occupational function, and
employees with substantial improvement in depressive symptoms after
receiving appropriate treatment rate themselves as much more able
to function effectively in the work environment (Berndt et al.
1998; Coulehan et al. 1997; Ormel et al. 1993). Furthermore,
improvement in major depression appears to be associated with
greater likelihood of remaining employed and less work absence due
to depressive symptoms (Claxton et al. 1999; Mintz et al. 1992;
Simon et al. 2000; Wells et al. 2000). However, two studies did not
find a relationship between improvement in depression and in
self-reported work function (Simon et al. 2002; Simon et al.
1998).

A study of short-term disability based on a nationwide Canadian
sample of employees of three large financial and insurance
companies (representing 12% of their sector) found that most
employees absent on depression-related disability were in fact
receiving appropriate pharmacological treatment and that prompt
initiation of pharmacological treatment shortened disability
absence (Dewa et al. 2003b). They also found the receipt of
pharmacological treatment did not predict earlier work return when
compared to those depressed employees who did not receive such
treatment. However, those employees on depression-related
disability who were not receiving antidepressants also reported
relatively fewer symptoms related to depression as compared to
those who were receiving antidepressants (Dewa et al. 2003a), a
finding that suggests that the severity of depression may have
differed across the two groups. It is also interesting to note that
the researchers observed an association between complexity, or
resistance to antidepressant treatment, and return to work. That
is, employees with complex patterns of use (i.e., those who
switched antidepressants or augmented their antidepressant use) had
relatively longer episodes of disability (Dewa et al. 2003b).
Several studies produced data suggesting that cognitive behavioural
therapy (CBT) has a beneficial effect on work function above and
beyond the impact of antidepressant medication (Hirschfeld et al.
2002; Mynors-Wallis et al. 1997; Sherbourne et al. 2001).
Hirschfeld and colleagues (2002) suggested that "[CBT]
psychotherapy has a direct effect on psychosocial functioning
through therapeutic work on issues that have relevance to
psychosocial functioning, such as the building of social
skills."

One important question is that of "synchrony": does change in
work ability occur in tandem with change in depression
symptomatology? An early review paper suggested that improvement of
work ability might occur well after resolution of depressive
symptomatology, i.e., that there might be a delay in the impact of
antidepressant treatment on work function (Mintz et al. 1992).
However, subsequent research has not supported this idea. It has
been determined that change in work ability is, for the most part,
simultaneous with change in depressive symptomatology - as
depression resolves, work function is restored. (Berndt et al.
1998; Judd et al. 2000; Kocsis et al. 2002; Miller et al. 1998;
Sherbourne et al. 2001). Most of the improvement in depression
symptoms or work function is evident in a few months following
initiation of treatment. There is some indication that adverse
effects of antidepressants may be of concern for recovery of work
function: a recent study found that some employees experienced
antidepressant side effects that interfered with work performance,
including sleep disturbance, poor concentration, lack of motivation
and a "numbing down of feelings and responses" (Haslam et al.
2003).

Despite substantial effectiveness of standard treatments for
depression with regard to recovery of work function, it has also
been demonstrated that there is a significant degree of residual
impairment in function after treatment. A study of depression
treatment in primary care provides detailed information concerning
the relationship between depression treatment and recovery of work
function (Simon et al. 2000). After 12 months of appropriate
treatment with antidepressant medication, 41% of patients with
major depression were no longer depressed (i.e., they were in full
remission) and had six days of depression-related job absence in
the year; 47% were improved but still had significant depressive
symptoms (i.e., were in partial remission), with 11 days of
depression-related job absence; 12% remained persistently depressed
(had no remission) and had 17 days of depression-related job
absence. Furthermore, one study found that even in those who have
fully recovered from major depression according to clinical
criteria, some degree of reduced work capacity is evident, and it
concluded that this subset of patients might benefit from specific
psychosocial interventions designed to foster more complete
rehabilitation (Kocsis et al. 2002).

There is some emerging evidence that a disability management
approach, similar to that applied to recovery from musculoskeletal
injury, may yield significantly improved work recovery for
depression-related work impairment (Burton and Conti 2000;
McCulloch et al. 2001).

Several studies have examined the impact of depression on work
disability associated with other health problems. In a sample of
114 physically injured persons who were receiving workers'
compensation benefits and vocational rehabilitation, Ash and
Goldstein (1995) found that subjects with moderate or severe
depression were significantly less likely to return to work than
patients with less severe depression. Similarly, a Swedish study
(Soderman et al. 2003) of 198 employed patients who had recently
experienced an acute myocardial infarction or had been treated with
coronary by-pass surgery or coronary angioplasty found that
clinical depression before intervention exerted a great influence
on work resumption. Chronic pain conditions constitute a
substantial proportion of long-term disability cases in many
workplaces (Faucett and McCarthy 2003), and there is evidence that
depression is a substantial predictor of long-term disability in
employees with chronic pain (Ericsson et al. 2002). Similarly,
fibromyalgia is a frequent cause of disability that has been found
to have a significant relationship to mental health (Wolfe et al.
1995).

Major Trends in Research

With an increasing realization of the importance of disability
management and the need for successful approaches to assist people
in their return to work, there has been intensified interest and
activity in these areas of research. New models and methods have
been developed and recommended recently, and, although these may
not have been designed specifically to address mental health
problems, they may be applicable in future studies of this
population.

Franche and Krause (2002) at the University of Toronto's
Institute of Work and Health have proposed a new "Readiness for
Return-to-Work Model" that focuses upon the interpersonal context
of the work-disabled employee. In this model, employee interactions
with the workplace, the healthcare system and the insurance system
are considered as they affect the three defining dimensions of
change - decisional balance, self-efficacy and change processes.
The model was designed to account for individual variation in
optimal stage-specific timing of interventions based on an
individual's readiness to return to work. Thus, interventions to
assist return to work may be applied at the time most appropriate
for the individual, thereby faciliting improved outcomes.

Following a review of the literature on the design, conduct and
evaluation of occupational injury interventions, one group of
investigators found randomized controlled trials to be rare and
noted that quasi-experimental studies had often used the weakest
designs (Zwerling et al. 1997). They recommended a hierarchical
approach to evaluating occupational injury interventions, beginning
with qualitative studies, following up with simple
quasi-experimental designs using historical controls, continuing
with more elaborate quasi-experimental designs comparing different
firms' experience, and, when necessary, conducting randomized
controlled trials.

Fisher (2003) utilized a survey tool, the "Return to Work
Perception Survey," to examine the perception of various
supervisors and front-line workers of factors related to return to
work, including company policies and procedures, job satisfaction,
worker relationships and work environment. Significant differences
were found in the responses of supervisors and front-line
workers.

Researchers in the Department of Community Health Sciences at
the Université de Sherbrooke have developed the Work Disability
Diagnosis Interview (WDDI) to assist in the detection of prognostic
factors for disability in patients with sub-acute or chronic
musculoskeletal pain (Durand et al. 2002). The WDDI, which was
developed through systematic methodology, is composed of open-ended
questions about physical, psychosocial, occupational and
administrative factors that have been collated into an interview
form used at the first encounter with a disabled worker. Initial
applications have demonstrated a high prevalence of
socio-demographic, work-related, and psychosocial factors that may
contribute to prolonged work absence and have enabled clinicians to
develop appropriate rehabilitation plans.

Mustard and colleagues (2003) at the University of Toronto's
Institute of Work and Health utilized surveillance data to
investigate trends in the incidence of work-related morbidity and
disability in Ontario. Time series estimates of workplace injuries
and work-related disability based on two panel surveys for the
period 1993-1998 were compared with rates of work-related injury
and illness compensation claims during the same period. The
investigators found that, over the six-year period, lost-time
compensation claims declined by 28.8%, self-reported work-related
injury declined by 28.2% and the self-reported incidence of work
absence for work-related causes declined by 32.2%. Thus, three
independent data sources indicated reductions in work-related
morbidity during the period of observation. The researchers
interpreted these findings to mean that there has been an important
reduction in injury risk in Ontario workplaces over the past
decade.

Some recent studies have applied qualitative methods to study
disability management and return to work. In a study undertaken at
the University of Toronto's Joint Centre for Bioethics, the authors
examined how people living with HIV/AIDS perceive, attach meaning
to and approach the experience of returning to work (Nixon and
Renwick 2003). They found that participants were influenced by, and
wrestled with, both the dominant societal perspective that "people
should return to work," and the opposite perspective that people
with HIV/AIDS "should not return to work." A theoretical
understanding of the results was developed through the use of the
concepts of the "sick role" and the "hierarchy of identities."

In another qualitative study, researchers in three Canadian
provinces explored the perceptions of many different actors
involved in return-to-work programs for injured workers, studying
their views on successful strategies, barriers and facilitators of
the return to work process (Baril et al. 2003). The investigators,
who analyzed the underlying dynamics of their different
experiences, found that roles and mandates of the different groups
of actors (injured workers, other workplace actors and actors
outside the workplace), while sometimes complementary, could also
differ, leading to tension and conflict. Human resources managers
and healthcare professionals tended to attribute workers'
motivation to their individual characteristics, whereas injured
workers, worker representatives and health and safety managers
described workplace culture and the degree to which workers'
well-being was considered as having a strong influence on workers'
motivation. Non-workplace issues included confusion stemming from
the compensation system itself, communication difficulties with
some treating physicians and role conflict on the part of
physicians wishing to advocate for patients whose problems were
non-compensable. Several common themes emerged from the experiences
related by the wide range of actors, including the importance of
trust, respect, communication and labour relations in the failure
or success of return-to-work programs for injured workers.

A number of studies have used mixed methods in studies of
disability management and return to work. A Finnish study evaluated
outcomes of the "Pathway-to-Work Project," which aimed at tailoring
return-to-work plans for 140 middle-aged, long-term unemployed
participants with various disabilities and getting half of them
into work or training (Juvonen-Posti et al. 2002). The research
design comprised three parts: a quantitative quasi-experimental
component with a matched control group, a register follow-up and
the collection of qualitative data. The main variables used to
evaluate the outcomes were (1) changes in the labour market
situation during the two-year register follow-up, (2) changes in
distress, perceived competence and sense of coherence during the
intervention and (3) description of the process in the project.
After two-year follow-up, 14% of the participants were at work and
59% unemployed, whereas 9% of the control group were at work and
86% unemployed. The participants' distress level decreased
remarkably, and their perceived competence increased, but their
sense of coherence did not change. The investigators concluded that
even carefully tailored client work enables only some of the
long-term unemployed people with disabilities to cross the job
threshold and that other kinds of policy, strategy and intervention
are needed to link the return-to-work interventions more closely
with work, work places and enterprises.

Becker and colleagues (2000) have described methods for their
work in progress, which will evaluate four workplace prevention
and/or early intervention programs designed to change occupational
norms and reduce substance abuse at a major US transportation
company. The four programs are an employee assistance program,
random drug testing, managed behavioural healthcare and a peer-led
intervention program. An elaborate mixed-methods evaluation is
planned, combining data collection and analysis techniques from
several traditions. A process improvement evaluation focuses on the
peer-led component to describe its evolution, document the
implementation process for those interested in replicating it and
provide information for program improvement. An outcome assessment
evaluation examines the impacts of the four programs on job
performance measures (e.g., absenteeism, turnover, injury and
disability rates) and includes a cost-offset and employer
cost-savings analysis. Issues related to using archival data,
combining qualitative and quantitative designs, and working in a
corporate environment are discussed.

In a study of 108 supervisors who were provided with a 1.5-hour
training session to reinforce a proactive and supportive response
to work-related musculoskeletal symptoms and injuries, results
showed improvements in supervisor confidence to investigate and
modify job factors contributing to injury, to get medical advice
and to answer employees' questions related to injury and treatment
(McLellan et al. 2001). More supervisors reported decreases (38.5%)
than increases (9.6%) in lost work time in their departments.

Significant Gaps in Knowledge

Canadian representation and sponsorship were included in an
international research project on job retention and return-to-work
strategies for disabled workers undertaken by the International
Labour Office and GLADNET (the Global Applied Disability Research
and Information Network on Employment and Training). A code of
practice for managing disability in the workplace has been
published by the International Labour Office (ILO 2002). However,
research into the utility and uptake of the code has not yet been
developed.

Researchers have begun to study questions that can improve
disability policies and practices, but such research has not yet
been developed significantly in Canada. In the United States, Sim
(1999), using research by experts on return-to-work practices in
Germany and Sweden, examined the following three approaches that
have been suggested for improving the rate of rehabilitation of
disabled workers: (1) intervening as soon as possible after a
disabling event to promote and facilitate return to work, (2)
identifying and providing necessary return-to-work assistance and
managing cases to achieve return-to-work goals and (3) structuring
cash and health benefits to encourage people with disabilities to
return to work. Potential benefits and limitations were discussed
in the application of these approaches in the US environment.
Another study assessed the impact of US federal programs, such as
Social Security Disability Insurance, vocational rehabilitation,
medical insurance and psychiatric services, upon employment, by
conducting a qualitative study of 16 employed and 16 unemployed
individuals with psychiatric disabilities (O'Day and Killeen
2002).

All participants had disabilities severe enough to qualify them
for Social Security Disability benefits. However, they reported
that the federal policies and practices encouraged employment and
integration of only a few participants in a particular stage of
their recovery and placed significant barriers in the employment
path of others. Studies of policies and their influence on
disability management and return to work are needed in Canada.

There is a need to study disability management and
return-to-work factors related to anxiety disorders, such as social
phobia and panic disorder, given their prevalence and the low
availability of appropriate treatment resources (Lepine 2002;
Wittchen and Fehm 2001). In workplaces where there is a high risk
of traumatic events, evidence-based approaches to disability
management and return to work are needed in order to support
individuals with post-traumatic stress disorder and work-related
injuries (Asmundson et al. 1998).

Similarly, disability management and return-to-work factors
related to problem substance use requires study (Becker et al.
2000). The high prevalence of substance use disorders and their
co-existence with other mental health problems are important
reasons to address this significant gap in the research
literature.

Although some important research studies of disability
management for depression have been done, there has been only
limited study of the impact of depression on work disability
associated with other health problems. In a sample of 114
physically injured persons who were receiving workers' compensation
benefits and vocational rehabilitation, Ash and Goldstein (1995)
found that subjects with moderate or severe depression, defined as
having a score greater than 16 on the Beck Depression Inventory
(BDI), were significantly less likely to return to work than
patients with less severe depression (for back-injured patients,
odds ratio (OR = 31, 95% CI [8.8, 108]). BDI scores correctly
classified 84% of the back-injury and 86% of the other-injury
groups with respect to their return to work. The level of workers'
compensation benefit was the only variable that added (marginally)
to the predictive power of the BDI.

Similarly, a Swedish study (Soderman et al. 2003) of 198
employed patients who had recently experienced an acute myocardial
infarction (AMI, n = 85) or had been treated with coronary by-pass
surgery (CABG, n = 73) or coronary angioplasty (PTCA, n = 40) found
that clinical depression before intervention (&Mac179;16 as
measured by the Beck Depression Inventory) exerted a great
influence on work resumption both at full time (OR = 9.43, 95% CI
[3.15, 28.21]) and at reduced working-hours (OR = 5.44, 95% CI
[1.60,18.53]). Mild depression (BDI 10-15) influenced only work
resumption at full time (j88 = 2.89, 95% CI [1.08,7.70]). More
research is needed in order to elaborate the degree to which
treatment of depression enhances work resumption rates for a
variety of health problems.

Chronic pain conditions constitute a substantial proportion of
long-term disability cases in many workplaces (Faucett and McCarthy
2003), and there is evidence that depression is a substantial
predictor of long-term disability in employees with chronic pain
(Ericsson et al. 2002). Similarly, fibromyalgia is a frequent cause
of disability that has been found to have a significant
relationship to mental health (Wolfe et al. 1995). Research in
disability management and return-to-work factors related to these
conditions is needed.

In the multicultural environment of Canada, cultural factors
related to disability management require research study. Yip and Ng
(2002) have described Chinese cultural dynamics of unemployability
of male adults with psychiatric disabilities. Further research on
issues that affect various populations is needed.

Summary and Promising Research Directions

In an article in 1993, Rachel Jenkins asked why mental health at
work was so under-researched (1993). More than a decade later, the
same question remains relevant. There are many gaps in knowledge to
be filled. Little is known regarding best practices in managing the
disability associated with the most prevalent mental disorders
(i.e., depression, anxiety disorders and substance use disorders).
Although some information is available to assist people with severe
mental disorders in obtaining employment, knowledge to help people
maintain employment is lacking. Additionally, knowledge regarding
systemic factors that influence disability management and return to
work (e.g., employee assistance programs and disability insurance
regulations) relevant to people with mental disorders is yet
unavailable.

There are several promising directions for research:

Application of disability management principles to a variety
of psychiatric disorders. Until recently, the focus of
disability management has been on physical disabilities,
particularly musculoskeletal injuries. Disability management models
have not been applied systematically to a variety of psychiatric
disorders: research is needed in this area.

Understanding the impact of disability management for mental
health problems in relation to various physical health
problems. Disability management and return to work following
physical conditions such as musculoskeletal injury, coronary heart
disease, chronic pain syndromes and fibromyalgia require study in
relationship to mental health and mental illness.

The relationship of population factors in disability
management and return to work. It is likely that a variety of
approaches to disability management and return to work may be
applicable to specific populations. Issues related to culture,
gender, age and environment should be accounted for in future
research.

Policies and guidelines relevant to occupational
disability. Existing guidelines for the assessment and
treatment of mental illness have neglected workplace functioning.
There is a need for the development and evaluation of protocols to
guide practitioners in interventions to enhance or restore work
function. Furthermore, there are important questions regarding the
optimal role of different health practitioners in working
collaboratively to foster work return of psychiatrically-disordered
individuals: e.g., which health provider should act as the main
referral agent for work entry programs, what skills should family
physicians have in order to evaluate depression-related work
disability, etc.

Effectiveness of standard mental healthcare in restoring
work function. The outcomes of standard healthcare for
psychiatric disorders vis à vis recovery of work function have not
been well established. How effective is the existing Canadian
mental health system at fostering employability and employment of
individuals with severe psychiatric disorders? How effective is
this system at fostering work return in depression and anxiety
disorders?

Innovative approaches to mental healthcare. Controlled
outcome research is needed on innovative approaches to the delivery
of mental healthcare that could lead to improved outcomes for
recovery of previously adequate work function; shortening of
disability absence related to psychiatric disorder; and enhancement
of functional level for those who have not been successfully
employed.

Organizational interventions to foster recovery of work
function in individuals with disability related to mental health
problems. Examples of organizational interventions might
include changes in employee assistance programs or in the structure
of health benefits to increase access to evidence-based health
services.

About the Author

Elliot Goldner, MD, MHSc, FRCPCDivision of Mental Health Policy and Services University of British Columbia

Dan Bilsker, PhD Division of Mental Health Policy and Services University of British Columbia

Merv Gilbert, PhD Division of Mental Health Policy and Services University of British Columbia

Larry Myette, MDDivision of Mental Health Policy and Services University of British Columbia

Marc Corbière, PhDDivision of Mental Health Policy and Services University of British Columbia

Kazimirksi, J.C. 1997. "The Physician's Role in Helping Patients Return to Work after an Illness or Injury." Canadian Medical Association Journal 156(5): 680.

Kenny, D. 1994. "Determinants of Time Lost from Workplace Injuries: The Impact of the Injury, the Injured, the Industry, the Intervention and the Insurer." International Journal of Rehabilitation Research 17(4): 333-42.